Treating Insomnia &Nightmares After Trauma: Impact on Symptoms &Quality of Life This application addresses broad Challenge Area (04) Clinical Research and specific Challenge Topic, 04-NR- 103* Improving Quality of Life of Patients and Family Following a War-Related Traumatic Injury With an increase in active combat operations in recent years, the number of military personnel exposed to trauma is growing rapidly. One debilitating and far-reaching consequence of trauma for some individuals is the development of Post-Traumatic Stress Disorder (PTSD), with approximately 20% of veterans exposed to war- related trauma developing the disorder. Recent estimates suggest the prevalence within Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans presenting for care at the VA is even higher. The short- and long-term negative consequences of PTSD for the individual, family, and society include reduced health- related quality of life, significant mental distress and comorbid psychiatric conditions, poor physical health, decreased family functioning, and loss of productivity. The healthcare consequences of these problems manifest in greater rates of self-reported poor health, increased numbers of primary care visits, and increased numbers of missed workdays. With increasing numbers of veterans returning from OEF/OIF, these personal and societal consequences are expected to grow in coming years. While effective treatments for the daytime symptoms of PTSD exist, they typically leave untreated the specific nighttime complaints of nightmares and insomnia. Nightmares and insomnia reported in the wake of traumatic events predict development of PTSD, and these disorders are independently associated with increased risk of health and psychiatric morbidities. Notably, chronic nightmares are associated with increased risk of substance abuse and suicide. Recognition of the negative impact of poor sleep and sleep disorders across patient populations has grown to the point where NIH convened a special conference in April 2009 entitled, "Sleepiness and Health Related Quality of Life" to highlight these issues. With respect to PTSD, studies have shown nightmares and insomnia often do not resolve without specifically targeted interventions, suggesting the negative consequences can build over more years. There are evidence-based treatments for both sleep disorders (Cognitive Behavioral Therapy for Insomnia, CBT-I;and Imagery Rehearsal Therapy, IRT), but they have not been thoroughly tested in individuals with military-related trauma, and no published studies report testing these interventions in recently deployed active duty personnel. Furthermore, it is unclear if treating sleep complaints will positively impact health-related quality of life and daytime symptoms more so than treatment focused only on daytime symptoms of PTSD. The overall objective of this study, then, is to examine if personalizing PTSD treatment by adding evidence-based sleep treatments in those patients with sleep complaints can better treat the full spectrum of PTSD symptoms (i.e., both daytime and nighttime) and improve health-related quality of life and overall clinical outcomes. This is a between-subjects randomized control trial. Participants with PTSD who also meet diagnostic criteria for both insomnia and recurring nightmares will be randomly assigned to one of two groups [Prolonged Exposure (PE) treatment only, or CBT-I/IRT + PE] equated for length of treatment. Assessments will be conducted at pretreatment, treatment weeks 5, 12, and 18, and post-treatment week 12. Assessments include objective and subjective measures of sleep disturbances, health-related quality of life, daytime PTSD symptoms, and other comorbid psychiatric symptoms. Patients will be recruited from the VA San Diego Healthcare System (where veterans are seen within a few month of returning from deployment) and the Naval Medical Center San Diego (where active duty personnel are seen even sooner post-deployment). To our knowledge: 1) this is the first study to examine the utility of CBT-I and IRT as an adjunct to other empirically validated PTSD treatments;2) it will have a greater sample size than any currently published trial in combat- related PTSD;3) it will be the first study to systematically examine these treatments in recently deployed active duty personnel;and 4) it will be the largest study of the sleep interventions to date to have health-related quality of life as a specifically targeted outcome. If our hypotheses are borne out, this study has the potential to provide valuable information in developing targeted treatment plans for combat-related PTSD, as well as to contribute to improvements in the overall well-being and quality of life in patients and, by extension, likely their families as well. Exposure to trauma, especially when it manifests as Post-Traumatic Stress Disorder, results in numerous negative consequences for patients, families, and society. Some of the most frequent, disturbing, and treatment resistant symptoms of PTSD are nightmares and insomnia. This study will examine whether treatments specifically targeted at those sleep disorders can improve clinical outcomes and increase health- related quality of life in individuals recently exposed to war-related trauma.